Become a Pioneer with Wiltshire CIL!
By signing up to become a Pioneer, you are joining a network of disabled people across the country. Share with us what topics interest you, and we will contact you when we are running projects you can get involved with. Let's make futures that are designed by and works for disabled people... This is our time!
Sign in to Google to save your progress. Learn more
Lucy Dellow *
04/02/1994th *
MM
/
DD
/
YYYY
Orchard Cottage, Lockeridge House, Lockeridge, Marlborough *
SN8 4EL *
ssglucy@gmail.com *
07723 745342 *
A Preferred Person

You can also choose to be contacted thorough a preferred person. A preferred person is someone you trust who you would like to receive information from us. This could be a parent, partner, teacher or someone else. 

Your preferred person does not need to be the same as your emergency contact.  

If you would like to be contacted through a preferred person, please fill in the following details: 

Preferred Person's Name

Preferred Person's Email Address

Preferred Person's Telephone Number

Who should we contact? *

Emergency Contact

An emergency contact is someone we will contact if you are in an emergency. This could be a parent, partner or someone else. 

If you are someone's preferred person and emergency contact, please fill in your details again. 

Jake Lovick

 *

Partner

 *

07940 966337

 *

Email Address

I have lived experience of the following (please select all that apply) *
Required
I wish to give my views on the following (please tick all that apply) *
Required

Other topics I would like to share my views about 

Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Get involved.

Does this form look suspicious? Report

Google Forms